GPs 'wasting millions of pounds' prescribing gluten free foods

The February issue of the Drugs and Therepeutics Bulletin, a BMJ
journal,has an editorial entitled "Prescribing foods?". I regret that
despite my forty years of BMA membership and BMJ readership, I can only
read an abstract, as I am considered a 'non-subscriber':
http://dtb.bmj.com/content/51/2/13.extract

So I must also link to a Daily Telegraph article. It is by the DT's
Medical Correspondent,
who I can assume HAS read the editorial:
http://www.telegraph.co.uk/health/healthnews/9868852/GPs-wasting-millions-
of-pounds-prescribing-gluten-free-foods.html

It appears that the D&TB editors have taken exception to the cost of
treating coeliacs in the UK, quoted at £27M/year. They claim that
prescription
"inhibits competition meaning a loaf of Gluten-free bread can cost more
than £5, compared with £3 in Tesco". They further claim that prescribing
gluten-free foods is unnecessary as they are freely available in shops.

I would ask if these two male editors, for surely, like the PM who
did not know what milk cost, if they have any idea how much an ordinary
loaf costs
in comparison? (£1.40) Or why they consider that coeliacs, with an
unpleasant, lifelong diesease that can be complicated by osteoporosis,
infertility, dermatitis, lactose intolerance, other autoimmune diseases
and Hodgkins lymphoma or adenocarcinoma, and is successfully treated at
relatively low cost should not have that treatment on the NHS? And why
coeliacs should be singled out against diabetics (annual cost to the NHS
?9.6BILLION) or asthmatics (?1 billion)?

I do not defend the provision of 'pizza bases', nor that anyone who
makes a 'life-style choice' to go gluten-free should get their chosen diet
on the NHS. I just plead that clinically diagnosed coeliacs, who have to
work hard to avoid the gluten that creeps into foods of many types, may be
provided with a palatable gluten-free bread, Glutafin Fresh, that is NOT
available without a prescription.

Dr.John Davies, FRCA
Albert House
Haverbreaks
Lancaster LA1 5BN

Conflict of Interest:

First, I must declare an interest. My partner is a coeliac, who must rigorously avoid gluten because otherwise she suffers
severe symptoms, abdominal pain, and diarrhoea.

Prescribing perfectly

In your leading article on this subject you ask reactions. As a
retired pharmacist with a long standing experience in community pharmacy I
recommend the following:

There is no perfect prescribing as long as this is left to humans.
Computers may be of help but their output is as good as their input may
be. Humans are never perfect, even doctors are not. The circumstances in
which they prescribe leave all chances for mistakes.

For that reason as early as the XIth century an independent and
separate task was given to the prescriber and the dispenser. In my opinion
this measure is the best safeguard to ensure good prescribing.

With to-day's many new drugs known as biologicals, it is almost
impossible for the prescriber to know all side effects or interactions.
Hence a close cooperation between prescriber and dispenser is very
necessary. This can be done over the telephone but sometimes it is
preferable that the two have a personal contact. The computer is not
always a reliable source of information. All side effects and interactions
and, eventually, the contra-indications will always be introduced later
than they got known.

In this country -the Netherlands- nearly everybody is linked to one
specific pharmacy. The advantage is that the pharmacist knows his patients
almost as well as their doctor. Through the regular FTOs
(pharmacotherapeutical meetings) organised by most pharmacists there is a
regular contact between the two groups. This is the base of a confidential
and professional relationship required for regular consultations.

This will in the long term result in far less prescription errors
than any highly advanced computer. Both groups nowadays cannot function
anymore without its help. But however advanced it is the human factor
which renders it successful.

And what applies to primary care should be copied in secondary care
in the same manner.

Neuropathic pain and pregabalin

The recent DTB update on the drug treatment of neuropathic pain.
Part 2: antiepileptics and other drugs (DTB 2012;50:126-129) is a welcome
summary of prescribing, and a reminder of the poor quality of the evidence
behind the guidance.

However, it may be prudent to add a warning about pregabalin.

The Summary of Product Characteristics (SPC)(1) states: Cases of
abuse have been reported. Caution should be exercised in patients with a
history of substance abuse and the patient should be monitored for
symptoms of pregabalin abuse.

A review(2) carried out in Canada concluded that while pregabalin was
not likely to be abused by non-drug abusing subjects, it does have
euphorigenic activity and may be subject to abuse in susceptible
populations.

In recent years, it has become apparent that pregabalin is used
recreationally, with initial reports that it is widely traded in prisons.
This has resulted in prison prescribing guidance(3) cautioning against its
routine use. Recent local reports suggest that street use has now become
widespread, pregabalin is increasingly offered as an alternative to
heroin, and overdoses have been reported. It is discussed in detail in
online drug users' forums - www.bluelight.ru has a "Wonders of Pregabalin"
thread.

There are also increasing concerns regarding the difficulty in
withdrawing pregabalin. The SPC(1) warns of withdrawal symptoms which
include insomnia, anxiety, flu like symptoms and convulsions.

Prescribers should be aware of these issues when considering
prescribing pregabalin for neuropathic pain. Consideration could be given
to the off label use of duloxetine as an option for patients with a
history of substance misuse, as recommended in the prison prescribing
guidance(3).

1. Summary of product characteristics
http://www.medicines.org.uk/EMC/medicine/14651/SPC/Lyrica+Capsules/
2. Canadian Agency for Drugs and Technologies in Health: Abuse and Misuse
Potential of Pregabalin: A Review of the Clinical Evidence; April 2012
http://www.cadth.ca/media/pdf/htis/april-
2012/RC0348%20Pregabalin%20draft%20report%20Final.pdf
3. Royal College of General Practitioners & Royal Pharmaceutical
Society: Safer Prescribing in Prisons Nov 2011
http://www.rcgp.org.uk/news/2011/november/~/media/Files/News/Safer_Prescribing_in_Prison.ashx

Mole checks on the high street

As a dermatologist involved in skin cancer management I read with
interest your article on mole checks on the high street and the concerns
raised by the All Party Parliamentary Group on Skin (APPGS). I gave
evidence to the APPGS and shared their concerns regarding the lack of
training in skin cancer diagnosis, for staff performing the clinical
examination in such clinics. The high street mole screening clinics were
invited to give evidence of their governance standards by the APPGS in
2008 and were criticised in the report for failing to do so. To highlight
the potential prevalence of misdiagnosis on the high street I would like
to give evidence about two cases seen within a month, to support the
concerns raised by the APPGS.

Case 1. A 46 year old lady presented requesting excision of a lesion
on her chin. She had recently visited a high street mole screening clinic,
where she was diagnosed with a suspected basal cell carcinoma (BCC). A
clinical and dermoscopic image had been taken and was sent for an overseas
tele-dermoscopic opinion. She received a phone call and a report 24 hours
later which confirmed a lesion suspicious for a BCC, and advised to have
surgery. Having prepared herself for surgery she attended my clinic where
a benign intradermal naevus was confirmed and she was reassured that no
surgery was required. This case does illustrate the limitations of tele-
dermoscopy when the referring ‘clinician’ is not medically trained, which
therefore gave false suspicion on a very benign lesion. Additionally
teledermoscopy for pink lesions has been shown to be less accurate than
face-to face diagnosis even for experienced dermatologists. 1

Case 2. A 32 year old man with a previous history of BCC sought skin
cancer screening as he had moved to the UK. He had a 12 month history of a
persistent pink macule on the right side of his neck at the edge of the
scar of his BCC excision. He was screened by a non-medically qualified
practitioner and a SIAScopic image was taken and sent for a remote (within
the UK) expert diagnosis. He received a report 3 weeks later stating that
all was well. The pink area remained and he sought a second opinion. On
examination he had an obvious clinical recurrence of his BCC. This was
completely excised and confirmed on histology. There were a number of
errors in his management. Firstly the history of previous BCC excision at
this site would make a diagnosis of recurrence highly suspicious on
clinical history alone. Secondly too much weight was placed upon a
SIAScopic image alone and not in the context of the history, leading to
misdiagnosis and mismanagement. The blood vessel patterns of BCCs can be
non-specific, from simple erythema to the typical arborizing
telangiectasia; the pressure applied for image acquisition may also impair
vascular structures. Thus the importance of an expert making the clinical
diagnosis face to face of pink lesions in patients at risk for skin cancer
should not be underestimated. 1 Additionally SIAScopy, a diagnostic tool
not routinely used by dermatologists, has been independently shown to be
less accurate than dermoscopy, which is the standard diagnostic tool for
skin lesion diagnosis. 2-3A large study, assessing the role of SIAScopy as
a diagnostic tool in primary care, is due to conclude in 2010.4 However,
until the results are available one cannot assume that this technology is
validated as a diagnostic test, without the support from evidence of this
study. Therefore the use of this technology at the present time is
contrary to the UK National Screening Committee recommendations for
screening where there should be ‘ a simple, safe, precise and validated
screening test’.4

These two cases reflect the potential for misdiagnosis of skin cancer
that may occur when commercial organisations and non-experts are involved
in skin cancer diagnosis, namely a false positive or a false negative
diagnosis. Sadly these two cases may be the tip of the iceberg as I have
additional cases and I am aware of other dermatologists having similar
experiences, although with an absence of a central database for reporting
such activity formal evidence may be lacking. These cases do however
support the concerns raised by the APPGS on the standard of diagnosis at
these clinics and additionally give evidence towards poor standard of care
as illustrated. Further evidence should be sought to answer or dispel the
concerns of the APPGS more thoroughly. With the evidence supplied, the
continuing expansion of high street clinics offering skin cancer screening
is a concern particularly as many such clinics promote themselves to the
public as the experts in mole diagnosis and skin cancer screening; the
public should be made aware that firstly there is no evidence to support
this claim and secondly evidence to the contrary exists.